FORMAT PENGAKJIAN KEPERAWATAN ANAK

Data diambil tanggal : 05-November-2018………………………

Ruang rawat/kelas : Ruang Shofa 6……………………………
No. Rekam Medik : 30-81-XX……………...…………………

I. IDENTITAS ANAK IDENTITAS ORANG TUA

Nama : An. K Nama Ayah : Tn. F
Tanggal lahir : 16-10-2017 Nama Ibu : Ny. R
Jenis kelamin : Perempuan Pekerjaan ayah/ibu : Swasta/IRT
Tanggal MRS : 05-10-2018 Pendidikan ayah/ibu : SMP/SMA
Alamat : Usman Sadar 16 Agama : Islam
Diagnosa medis : GEA, DHB, TF Suku/bangsa : Indonesia (Jawa)
Sumber informasi : Orang tua Alamat : Usman Sadar 16

II. RIWAYAT KEPERAWATAN

1. Riwayat keperawatan sekarang
a. Keluhan utama :
Anak lemas dan muntah…………………………………………………………..
b. Riwayat penyakit saat ini :
Anak datang ke IGD dengan keluhan lemas sejak tadi pagi, mual muntah
disertai diare 4x, makan minum menurun sejak kemarin, kencing sedikit, batuk
pilek dan panas sejak 2 hari yang lalu…………………………………………….
2. Riwayat keperawatan/Penyakit sebelumnya
a. Riwayat kesehatan yang lalu :
 Riwayat prenatal : Ibu tidak menkonsumsi obat-obatan dan tidak ada keluhan
parah, hanya mual muntah biasa.
 Riwayat antenatal : Bayi lahir aterm (persalinan Caesar, BB lahir : 3900
gram, persalinan dibantu oleh bidan .
 Riwayat postnatal : Menurut ibu pasien, pasien lahir normal, tidak ada
keluhan dan pergerakan aktif.
 Penyakit yang pernah diderita :
Demam Kejang Batu/pilek
Mimisan lain-lain ……………………
 Operasi : Ya Tidak Tahun :
 Alergi : Makan Obat Udara
Debu Lainnya, sebutkan ….
 b. Imunisasi :BCG 1x Polio….4….X DPT…3….X
Campak 1x Hepatitis…1…X

Masalah Keperawatan:
……………………………………………………………………………………
……………………………………………………………………………………
…………………………………………………………………………………….

3. Riwayat kesehatan keluarga

a. Penyakit yang pernah diderita oleh anggota keluarga :
.................................................................................................................................
b. Lingkungan rumah dan komunitas :
Pasien dan keluarga tinggal disebuah rumah kontrakkan dan memiliki cukup
ventilasi
c. Perilaku yang memepngaruhi
kesehatan............................................................................................................
d. Persepsi keluarga terhadap penyakit anak
Keluarga tau tentang penyakit anaknya..............................................................

Masalah Keperawatan:
…………………………………………………………………………………
…………………………………………………………………………………
…………………………………………………………………………

4. Kesadaran :
Apatis, GCS : 2-3-3...............................................................................................
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5. TTV : Suhu : 38,4 ̊C....................................................................
TD : ...............................................................................
RR : 28x/menit...............................................................
Nadi : 140x/menit.....................................................................
6. Riwayat pertumbuhan dan perkembangan :
 BB saat ini : ..7,4...Kg, TB : .100... cm
 LK : ..46..... cm, LD : .....cm, LLA :..16..cm
 BB lahir :....3900.....gr BB sebelum sakit : ...........kg
 Panjang lahir :...47....cm
 Pengkajian perkembangan (DDST)/DDTK : Ibu mengatak tidak ada
keterlambatan perkembangan anaknya, sudah bisa berjalan, berbicara dan
meyusun gambar.
 Tahap perkembangan Psikososial :
 Pasien senang diajak bermain, sering menirukan kegiatan orang lain terutama
orang tua
 Tahap perkembangan Psikoseksual :
.......................................................................
Masalah Keperawatan:
…………………………………………………………………………………
…………………………………………………………………………………
…………………………………………………………………………

III. POLA FUNGSI KESEHATAN

1. Pola penatalaksanaan kesehatan / persepsi sehat
Ibu pasien mengatakan bahwa kesehatan sangatlah penting, ibu pasien mengatakan
sangat khawatir melihat keadaan anaknya yang lemas karena diare terus-menerus dan
demamnya tinggi padahal sudah diberikan obat sesuai dengan resep dokter...............
......................................................................................................................................
......................................................................................................................................
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Masalah Keperawatan :
......................................................................................................................................
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2. Pola Nutrisi– Metabolik

Ibu pasien mengatakan anaknya belum diperbolehkan makan sampai di ijinkan oleh
dokter, pasien hanya boleh minum saja........................................................................
......................................................................................................................................
......................................................................................................................................
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Masalah Keperawatan :
Nutrisi kurang dari kebutuhan......................................................................................
......................................................................................................................................
......................................................................................................................................

3. Pola Eliminasi
Eliminasi Alvi
Ibu pasien mengatakan dalam sehari anaknya BAB lebih dari 4 kali dan BAB nya cair
berwarna kuning...........................................................................................................
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......................................................................................................................................
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Eliminasi Uri
Ibu pasien mengatakan anak BAK nya sangat sedikit sekali tidak seperti biasanya....
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Masalah Keperawatan :
Deficit Volume Cairan..................................................................................................
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4. Pola Istirahat dan tidur
Ibu pasien mengatakan anaknya tidur siang ±4 jam dan tidur malam ±10 jam. Namun,
saat sakit anak sering terbangun saaat tidur...................................................................
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Masalah Keperawatan :
Gangguan Pola Tidur....................................................................................................
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5. Pola Aktifitas - Latihan

Anak berkembang sesuai dengan usianya saat ini dan aktivitas sehari-hari hanya bermain.
Namun saat sakit anak hanya terbaring lemah ditempat tidur.......................................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
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Masalah Keperawatan :
Hambatan Mobilitas Fisik............................................................................................
......................................................................................................................................
......................................................................................................................................

6. Pola kognitif – perseptual – keadekuatan alat sensori

Pasien dapat mendengar dengan jelas dan pasien dapat melihat dengan normal.........
......................................................................................................................................
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Masalah Keperawatan :
Tidak ada masalah keperawatan...................................................................................
......................................................................................................................................
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7. Pola persepsi dan konsep diri

Pola persepsi
...........Ibu pasien sangat khawatir melihat anaknya lemah karena diare terus menerus dan
demamnya tidak turun-turun........................................................................................
......................................................................................................................................
......................................................................................................................................
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Konsep diri
a. Gambaran diri
Tidak terkaji..................................................................................................................
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......................................................................................................................................
b. Harga diri
Tidak terkaji..................................................................................................................
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c. Ideal diri
Pasien adalah seorang anak perempuan........................................................................
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......................................................................................................................................
d. Peran diri
Pasien berusia satu tahun dan belum duduk dibangku sekolah....................................
......................................................................................................................................
e. Identitas diri
Pasien adalah anak pertama dari satu bersaudara.........................................................
......................................................................................................................................
......................................................................................................................................

Masalah Keperawatan :
Tidak ada masalah keperawatan...................................................................................
......................................................................................................................................
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8. Pola Reproduksi Seksual
Pasien berjenis kelamin perempuan..............................................................................
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Masalah Keperawatan :
Tidak ada masalah........................................................................................................
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9. Pola hubungan peran

Persepsi klien tantang pola hubungan
Pasien dekat dengan ibu, ayahnya dan neneknya.........................................................
......................................................................................................................................
......................................................................................................................................
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Persepsi klien tentang peran dan tanggung jawab

Pasien masih dalam tanggung jawab penuh orang tuanya...........................................
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Masalah Keperawatan :
Tidak ada masalah keperawatan...................................................................................
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10. Mekanisme Koping

Kemampuan mengendalian stress
Saat anak menangis ibu atau neneknya langsung menggendong pasien agar pasien tidak
menangis lagi................................................................................................................
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......................................................................................................................................
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Sumber pendukung
Keluarga pasien (ayah,ibu,nenek)................................................................................
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 ......................................................................................................................................
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Masalah Keperawatan :
Tidak ada masalah keperawatan...................................................................................
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11. Pola tata nilai dan kepercayaan

Pasien dan keluarganya beragama islam. Orang tua pasien selalu berdoa untuk
kesembuhan anaknya ...................................................................................................
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Masalah Keperawatan :
Tidak ada masalah keperawatan...................................................................................
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12. Pemeriksaan Refleks

Refleks : Fisilogis

Dextra Sinistra Dextra Sinistra

Biceps Triceps
\ \
Dextra Sinistra Dextra Sinistra

Knee Achiles
\
Refleks Patologis

Masalah Keperawatan :
……………………………………………………………………………………
……………………………………………………………………………………
……………………………………………………………………………………

13. Aspek Sosial

a. Ekspresi efek dan emosi : Senang Sedih

Menangis
Cemas Marah Diam
Takut Lain ...................................
b. Hubungan dengan keluarga :
Akrab Kurang akrab
 c. Dampak hospitalisasi bagi anak :
..........................................................................................................................................
..........................................................................................................................................
Dampak hospitalisasi bagi orang tua :
Orang tua pasien cemas dan bingung saat melihat anaknya
menangis ..........................................................................................................................
..........................................................................................................................................
................

Masalah Keperawatan :
……………………………………………………………………………………
\
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14. Pemeriksaan Penunjang

1. Pemeriksaan Laboratorium
.................................................................................................................................
GDA = 124...............................................................................................................
Hb = 13,6.................................................................................................................
PCV = 38,8..............................................................................................................
Leukosit =9300........................................................................................................
2. Pemeriksaan Radiologi
.................................................................................................................................
Widal = s. Paratyphi bo=1/80..................................................................................
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3. Pemeriksaan Lain – lain

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4. Terapi dan Diet.

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DAFTAR MASALAH KEPERAWATAN

1 Nutrisi kurang dari kebutuhan ……..……………………………………………

2 Deficit volume cairan …………………………………………………………...
3 Gangguan pola tidur …………………………………………………………….
4 Hambatan mobilitas fisik ……………………………………………………….
Surabaya,
Preceptee
 (……………………….)
Analisa Data
No Data Etiologi Masalah

1. DS : Gastroenteritis Kekurangan
Ibu klien mengatakan anaknya
volume cairan
BAB 4 x sehari Diare
DO :
- Klien terlihat rewel Frekuensi BAB meningkat
- BAB klien terlihat cair
- Turgor kulit klien menurun Hlang cairan dan elektrolit
- Klien terlihat lemas berlebihan

Kekurangan volume cairan

2. DS : Gastroenteritis Ketidakseimbangan
Ibu klien mengatakan anaknya
nutrisi kurang dari
belum boleh makan oleh dokter, Diare
anaknya hanya boleh minum saja. kebutuhan
DO : Anoreksia
- Klien terlihat lemas
- Turgor kulit menurun Mual muntah
- Klien rewel
Ketidakseimbangan nutrisi
kurang dari kebutuhan

3 DS : Gastroenteritis Gangguan pola

Ibu Klien mengatakan anaknya
tidur
susah tidur Diare
DO :
- Klien terlihat lemas. Reflex spasme otot dinding perut
- Mata klien terlihat sayup.
Nyeri akut

Gangguan pola tidur

Diagnosa Keperawatan
1. Kekurangan volume cairan b.d kehilangan cairan dan elektrolit berlebih
2. Ketidakseimbangan nutrisi kurang dari kebutuhan b.d mual muntah
3. Gangguan pola tidur b.d nyeri akut
No Diagnosa Keperawatan Tujuan Kriteria Hasil Intervensi
1. Kekurangan volume Setelah dilakukan - Input dan output Fluide management
cairan b/d output tindakan keperawatan cairan elektrolit 1 Timbang popok/pembalut
berlebih selama 3x24 jam, seimbang. jika diperlukan.
diharapkan kebutuhan - Menunjukkan 2 Pertahankan catatan intake
cairan dan elektrolit membrane dan output yang akurat.
dalam tubuh pasien
3 Menitor status hidrasi
mukosa lembab
dapat teratasi. (kelembapan membrane
dan turgor
mukosa, nadi adekuat,
jaringan normal.
tekanan ortostatik) jika
 diperlukan.
4 Monitor vital sign.
5 Kolaborasikan cairan IV.
6 Monitor status nutrisi.
7 Dorong masukan oral.
8 Kolaborasi dengan dokter.
Hipovolenia Management
1 Monitor status cairan
termasuk intake dan
output cairan.
2 Monitor tingkat HB dan
hematocrit.
3 Monitor respon pasien
terhadap penambahan
cairan.
4 Monitor berat badan.
2. Gangguan nutrisi Setelah dilakukan - Berat badan ideal Nutrition management
kurang dari kebutuhan tindakan keperawatan sesuai dengan 1 Kaji adanya alergi
tubuh b/d intake selama 3x24 jam, tinggi badan. makanan.
makanan yang tidak diharapkan kebutuhan - Tidak ada tanda- 2 Kolaborasi dengan ahli
adekuat. nutrisi pasien dapat tanda malnutrisi. gizi untuk menentukan
teratasi. - Menunjukkan jumlah kalori dan nutrisi
peningkatan yang dibutuhkan pasien.
fungsi 3 Anjurkan pasien ntuk
pengecapan dari meningkatkan intake IV.
4 Anjurkan pasien untuk
menelan.
- Tidak terjadi meningkatkan protein dan
penurunan berat vitamin C.
5 Berikan substansi gula.
badan yang 6 Monitor jumlah nutrisi dan
berarti. kandungan kalori.
7 Berikan informasi tentang
kebutuhan nutrisi.